Exercise Guidelines For Cancer Survivors

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Med Sci Sports Exerc. Author manuscript; available in PMC 2021 November 09.
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Published in final edited form as:

Med Sci Sports Exerc. 2019 November ; 51(11): 2375–2390. doi:10.1249/MSS.0000000000002116.
Exercise Guidelines for Cancer Survivors: Consensus statement

from International Multidisciplinary Roundtable
Kristin L. Campbell1, Kerri Winters-Stone2, Joachim Wiskemann3, Anne M. May4, Anna
L. Schwartz5, Kerry S. Courneya6, David Zucker7, Charles Matthews8, Jennifer Ligibel9,
Lynn Gerber10,11, Stephen Morris12, Alpa Patel13, Trisha Hue14, Frank Perna15, Kathryn H.
Schmitz16
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1Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver,

Canada
2School of Nursing, Oregon Health Sciences University and Knight Cancer Institute, Portland
USA
3Division of Medical Oncology, National Center for Tumor Diseases (NCT) and Heidelberg
University Clinic, Heidelberg, Germany
4JuliusCenter for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht
University, Utrecht, The Netherlands
5School of Nursing, Northern Arizona University, Flagstaff, Arizona
6Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, Canada
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7Medical Director & Program Leader, Cancer Rehabilitation Medicine Services, Swedish Cancer
Institute, Swedish Health Services, Seattle, WA.
8MetabolicEpidemiology Branch, Division of Cancer Epidemiology and Genetics, National
Cancer Institute, Rockville, MD
9Havard Medical School, Boston, MA
10Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA
11Center for the Study of Chronic Illness and Disability, George Mason University, Fairfax, VA
12Physical Therapy, Wingate University, Wingate, NC
13Behavioral and Epidemiology Research Group, American Cancer Society, Atlanta, USA
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14Department of Epidemiology and Biostatistics, University of California San Francisco, San

Francisco, CA
15Division
of Cancer Control and Population Sciences, Behavioral Research Program, Health
Behaviors Research Branch, National Cancer Institute, Rockville, MD
16Public Health Science, Penn State Cancer Institute, Penn State College of Medicine, Hershey,
PA
Corresponding author: Kristin L. Campbell, Department of Physical Therapy, University of British Columbia, 212, 2177 Wesbrook
Mall, Vancouver, British Columbia, Canada V6T 1Z3, Phone: 604-827-4704, Fax: 604-822-1470, Kristin.campbell@ubc.ca.
Campbell et al. Page 2
Abstract
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Purpose: The number of cancer survivors worldwide is growing, with over 15.5 million cancer
survivors in the United States alone – a figure expected to double in the coming decades.
Cancer survivors face unique health challenges as a result of their cancer diagnosis and the
impact of treatments on their physical and mental well-being. For example, cancer survivors
often experience declines in physical functioning and quality of life, while facing an increased
risk of cancer recurrence and all-cause mortality compared to persons without cancer. The 2010
American College of Sports Medicine Roundtable was among the first reports to conclude that
cancer survivors could safely engage in enough exercise training to improve physical fitness and
restore physical functioning, enhance quality of life, and mitigate cancer-related fatigue.
Methods: A second Roundtable was convened in 2018 to advance exercise recommendations

beyond public health guidelines and toward prescriptive programs specific to cancer type,
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treatments and/or outcomes.
Results: Overall findings retained the conclusions that exercise training and testing was
generally safe for cancer survivors and that every survivor should “avoid inactivity”. Enough
evidence was available to conclude that specific doses of aerobic, combined aerobic plus
resistance training, and/or resistance training could improve common cancer-related health
outcomes, including anxiety, depressive symptoms, fatigue, physical functioning, and health
related quality of life. Implications for other outcomes, such as peripheral neuropathy and
cognitive functioning, remain uncertain.
Conclusions: The proposed recommendations should serve as a guide for the fitness and health
care professional working with cancer survivors. More research is needed to fill remaining gaps in
knowledge in order to better serve cancer survivors, as well as fitness and healthcare professionals,
to improve clinical practice.
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Keywords
cancer survivorship; exercise prescription; safety
1. INTRODUCTION
In the last decade, the United States has seen a 27% decline in cancer deaths due to early
detection and improved treatments for cancer. In turn, the number of cancer survivors is
growing, with over 15.5 million cancer survivors in the United States - a figure that is
expected to double by 2040(1). Improved prognosis has created a growing need to address
the unique health issues facing cancer survivors that result from the disease, its treatment,
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and related comorbid conditions. For example, the symptom of fatigue can persist in 25%
of cancer survivors many years after their treatment has ended and contributes to difficulty
returning to work, independent living and poor quality of life(2). Furthermore, risk of
developing of heart disease may be elevated by some cancer treatments and cardiovascular
mortality is emerging as a major competing cause of death in cancer survivors along with
cancer recurrence(3, 4). Cancer is also a disease strongly linked with aging, and almost
half of survivors are older than 70 years(5). The adverse synergistic effects of age, cancer
treatment, and related sequelae increase the total burden of cancer. Historically, clinicians
advised cancer patients to rest and to avoid physical activity, but early exercise research in
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the 1990’s and 2000’s challenged this advice.
In 2010 the American College of Sports Medicine convened a Roundtable meeting

composed of a team of clinical and research experts in the field of cancer and exercise
to develop the first set of exercise guidelines for cancer survivors(6). Drawing on studies
mainly in breast and prostate cancer survivors, the key findings from this review were that
exercise training was generally safe and well tolerated during and after cancer treatment
and could elicit improvements in some health outcomes. There was sufficient evidence
to conclude that exercise could improve physical fitness, physical functioning, quality of
life, and cancer-related fatigue. However, given the limited number of rigorously designed
studies at that time, there was insufficient evidence to inform specific exercise prescriptions
for any of these outcomes nor by cancer site or treatment type. Thus, the 2010 Roundtable
recommendations largely followed the 2008 Physical Activity Guidelines for adults with
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chronic conditions to aim for at least 150 minutes per week of aerobic activity, two or
more days a week of resistance training, and stretch major muscles groups daily when
possible, with specific exercise testing and program modifications based on health status and
cancer and treatment-related side effects(7). At a minimum, survivors were urged to “avoid
inactivity” and be as physically active as possible(6).
The 2010 ACSM recommendations came with the expectation that they would be updated
as the evidence grew and indeed, since that landmark publication the number of randomized
controlled exercise trials in cancer survivors has increased by 281% (PubMed Search
completed March 2018) to over 2500 published randomized controlled trials. Moreover, an
increasing number of calls for the integration of exercise into clinical cancer care have since
been issued (8–11). Thus, in 2018 the ACSM International, Multidisciplinary Roundtable
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on Physical Activity and Cancer Prevention and Control was convened to bring together an
international group of exercise and rehabilitation professionals and organizations with the
goal to update recommendations based on current evidence. The Roundtable meeting took
place on March 12–13, 2018 in San Francisco, California, USA, with 40 representatives
from twenty organizations across the world who came together to sponsor and attend this
meeting (Table 1). Roundtable members were invited to participate based on their clinical
and scientific expertise and were asked to contribute in one or more of the following areas:
1) Role of exercise in cancer prevention and control; 2) Efficacy of exercise to improve
cancer-related health outcomes (acute, late and long-term effects); and, 3) Translation of
evidence into the clinical and community settings. The outcome of the work in each of these
areas would be three separate, but related publications. The manuscripts were circulated to
professional organizations for review and to obtain their official endorsement.
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This paper will update evidence-based guidelines for exercise testing, prescription
and delivery in cancer survivors. As it was acknowledged that the general exercise
recommendations put forward in 2010 may be unachievable for cancer survivors with
physical limitations and that benefits may come from less exercise, a particular goal of
the 2018 Roundtable was to develop more granular exercise prescriptions for distinct cancer
related health outcomes to better guide fitness and other healthcare professionals who train
or care for cancer survivors. In the following sections we: 1) describe the evidence review
process and decisions for generating exercise prescriptions for specific cancer-related health
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outcomes; 2) provide evidence-based FITT (frequency, intensity, time, type) prescriptions

for outcomes with sufficient evidence (as outlined below); and 3) provide updates to
the 2010 guidelines around exercise testing and training, including special considerations
and safety precautions, specific to cancer survivors. We conclude by acknowledging the
limitations of this latest Roundtable and suggest directions for future updates.
2. UPDATE TO EVIDENCE-INFORMED EXERCISE PRESCRIPTIONS

2.1 Overview
Two a priori decisions were made by consensus at the Roundtable Meeting. The first was to
develop a list of cancer-related health outcomes with a high degree of clinical relevance for
which exercise may have therapeutic benefit (BOX 1). The second was to focus the review
of evidence primarily on traditional modalities of exercise including aerobic, resistance or
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combined aerobic plus resistance training on relevant health outcomes. A brief discussion on
other modalities of exercise (e.g., yoga) is provided at the end of the paper. Three additional
decisions were made by the writing team early on in the writing process where it was agreed
upon by consensus that: 1) components of physical fitness (e.g., aerobic capacity, muscular
strength/endurance) would not be categorized as cancer-health related outcomes, but would
be used to evaluate the adaptability and responsiveness of cancer survivors to specific modes
of exercise training; 2) exercise prescriptions would only be generated for outcomes where
there was sufficient evidence on the efficacy of exercise to improve a given outcome; 3)
beyond each outcome, the exercise prescriptions could not be further specified by tumor
type, phase of treatment or type of treatment due to the lack of sufficient evidence to do so in
a robust manner. The implications of these limitations are discussed later in the paper.
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2.2 Methodology for Evidence Review

To efficiently evaluate and provide a rich synthesis of the evidence, a review of published
randomized controlled trials, systematic reviews and meta-analyses for cancer-related health
outcomes (Box 1) using Medline/PubMed, EMBASE, the Cochrane Central Register of
Controlled Trials, CINAHL, the Physical Therapy Evidence Database (PEDro), and the
Cochrane Collaboration. A search was conducted from June-August 2018, for papers
published as of June 1, 2018, using standardized search terms for cancer and exercise,
in combination with search terms for the list of key cancer-related health outcomes
(Supplemental Materials). For each outcome, two writing team members reviewed the
resulting systematic reviews and meta-analyses to identify the most recent, relevant, and
high quality publications that could facilitate evaluation of the state of science around
efficacy of exercise for a particular outcome. If no systematic reviews and meta-analyses
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were identified, the available RCTs were reviewed.
A decision framework adapted from the Dutch Physical Activity Guidelines(12) was applied
to first determine whether or not there was sufficiently strong evidence to conclude that
exercise improved specific outcomes and in turn, warrant generation of an evidence-based
FITT prescription (Figure 1). Evidence for a given outcome was judged to be strong
when there were a substantial number of RCTs (≥5), the aggregate sample size was large
(n>150), and the beneficial effect of exercise was observed consistently across studies. For
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outcomes with a smaller number of RCTs (<5) or where the overall effect of exercise was
inconsistently observed or null, the level of evidence for an exercise benefit was judged as
insufficient. For such cases, a FITT prescription was not generated and only a summary of
current evidence and research recommendations were provided.
During the review process, authors felt that an intermediate category should be considered
for outcomes with >5 RCTs and an aggregate sample >150, yet heterogeneity for evidence
of an effect in cancer survivors. In these cases, if there were a consistent number of high
quality RCTs (designed and powered on the outcome of interest as the primary endpoint)
and that reported findings that were congruent with established evidence on the same
outcome in non-cancer populations, the evidence of exercise benefit for these outcomes was
judged as moderate and a FITT prescription was generated. However, more research would
be needed to confirm the exercise recommendation for these outcomes in cancer survivors.
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The next step was to define exercise prescriptions that conformed to the FITT formula and
outlined the type and dose of exercise expected to improve a given outcome. To streamline
the process, the evidence used to inform each exercise prescription was derived from high
quality systematic reviews and meta-analyses which also often provided separate analyses
on efficacy by FITT components to identify the most optimal exercise type, time, intensity
or frequency to improve a given outcome. However, if the quality of systematic reviews
was deemed low (AMSTAR rating <7), individual high-quality RCTs were used to derive
the prescription. FITT prescriptions and accompanying summary of the literature, which
informed them, were presented to the full writing team during a series of conference calls
for discussion and expert consensus (September – October 2018).
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2.3 Strong Evidence

For the following cancer-related health outcomes, there was consensus that benefit has been
consistently demonstrated and a FITT prescription was developed. Details of each FITT
prescription, including any unique considerations, by outcome are provided in Table 2.
When interpreting and applying a prescription, the exercise professional should be mindful
that the evidence is often disproportionately from trials in a single cancer type (i.e., breast),
but the prescription is assumed to generalize across cancer types unless otherwise specified.
In addition, studies often did not specifically target enrollment of individuals with the
poorest initial values of an outcome (e.g, high fatigue, low bone density) thus the efficacy of
a FITT prescription may or may not generalize to cancer survivors in greatest need.
2.3.1 Anxiety—A dose of moderate intensity aerobic training three times per week for
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12 weeks or twice weekly combined aerobic plus resistance training for 6–12 weeks can
significantly reduce anxiety in cancer survivors during and after treatment(13–17). Based on
sufficient evidence, it does not appear that resistance training alone reduces anxiety. There
is not sufficient evidence to determine whether or not there is a dose response relationship
between exercise intensity and changes in anxiety. Improvements in anxiety appear to be
greater in supervised training programs or those having a larger supervised component than
those that are predominantly unsupervised or home-based.
2.3.2 Depressive Symptoms.—Moderate intensity aerobic training performed three

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times per week and for at least 12 weeks or twice weekly combined aerobic plus
resistance training lasting 6–12 weeks can significantly reduce depressive symptoms in
cancer survivors during and after treatment(18, 19). Based on sufficient evidence, resistance
training alone does not seem to be effective for this outcome. Based on results from
high quality trials of aerobic training, there may be a dose-response effect where higher
volumes of aerobic exercise (90 min vs. up to 180 min/week) leads to better symptom
reduction. Improvements in depressive symptoms appear to be greater in supervised training
programs or those having a larger supervised component than those that are predominantly
unsupervised or home-based.
2.3.3 Fatigue—For training programs that last at least 12 weeks, engaging in moderate
intensity aerobic training three times per week can significantly reduce cancer-related
fatigue both during and after treatment(20–23). Moderate intensity combined aerobic plus
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resistance training sessions performed 2–3 times per week or twice weekly moderate
intensity resistance training may also be effective(21, 24–26), and the latter particularly in
prostate cancer(27). The effect of exercise was strongest for moderate to vigorous intensity
exercise whereas the effect for low intensity training was weak and this level of exercise
is unlikely to reduce fatigue(22, 24, 26, 28). Whether or not more exercise translates to
less cancer-related fatigue remains unclear, though there is suggestive evidence that the
reductions in fatigue are greater with exercise sessions longer than 30 minutes and programs
longer than 12 weeks compared to less exercise(29). There is insufficient evidence for a
linear dose response since going beyond 150 minutes per week of aerobic exercise does
not appear to result in the greatest reductions in fatigue. The efficacy of exercise for this
outcome appears to be independent of the level of supervision and/or setting for training(21,
27, 30).
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2.3.4 Health-related Quality of Life (HRQoL)—Combined moderate intensity

aerobic and resistance exercise performed 2–3 times per week for at least 12 weeks results
in improvements in HRQoL both during and after treatment(17, 31, 32). The benefit of
combined aerobic plus resistance training programs appears more potent than programs
consisting of only aerobic or resistance training(32). Though enough evidence favored the
efficacy of exercise to improve HRQoL, it should be noted that this particular outcome is
a construct that encompasses many factors and may have a more variable response than by
individual domains. For example, improvements seems to be more robust if the physical
functioning domain of HRQoL is the primary outcome and this will be covered separately.
Improvements in HRQoL appear to be greater in supervised training programs or those
having a larger supervised component than those that are predominantly unsupervised or
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home-based.
2.3.5 Lymphedema—There is a history of clinical recommendations to refrain from

aerobic or resistance training in order to avoid onset or exacerbation of lymphedema(33, 34).
For this particular outcome, an evidence-based exercise prescription is designed for safety
or no harm, versus the benefit of exercise to prevent lymphedema or improve lymphedema
symptoms, and limited to addressing upper extremity breast cancer-related lymphedema(35–
37). For resistance training, a general progressive program focused on large muscle groups
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performed 2–3 times per week, with the principle of “start low, progress slow” is safe
when supervised by a fitness professional(38–42). Insufficient evidence exists to conclude
whether or not starting a resistance training program without supervised instruction is safe
for women with or at risk for lymphedema after breast cancer. To date, there is insufficient
evidence to draw conclusions for aerobic exercise. In general, aerobic exercise seems to be
safe, with no significant increase in number of lymphedema-related adverse events reported
in studies investigating aerobic exercise(17). Based on preliminary evidence(43), the effects
seen in breast cancer may not translate for lymphedema following head and neck, bladder,
melanoma, gynecologic, or other cancer sites.
2.3.6 Physical Function—Moderate intensity aerobic training, resistance training or

combined aerobic plus resistance training performed three times weekly for 8–12 weeks
can significantly improve self-reported physical function(31, 32, 44). Broadly, supervised
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exercise appears to be more effective than unsupervised or home-based interventions(32),

although unsupervised programs may be effective in older cancer survivors(44). Further,
there is some evidence to suggest that if the intervention is unsupervised, physical function
could improve with higher weekly energy expenditure (MET-hr/week) but not weekly
exercise duration (min/week)(32). It should be noted that these results are based on
self-reported physical function, not objective measures where the evidence base on these
outcomes remains immature and more challenging to aggregate due to the variation and
limitations of assessment techniques.
2.4 Moderate Evidence

2.4.1 Bone Health—Two recent systematic reviews in cancer survivors concluded that
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across all trials the evidence for exercise to improve bone health is inconsistent(45, 46),
though RCTs that were designed with bone health as the primary outcome were largely
consistent with the exercise recommendations in the ACSM Position Stand for exercise
and bone health(47). In cancer, the majority of evidence is derived from trials in breast
and prostate cancer patients in the post-adjuvant treatment setting, which indicates that a
one-year supervised program of combined moderate-vigorous intensity resistance plus high
impact training (i.e., exercise that generates ground reaction forces above 3–4 times body
weight) performed 2–3 days per week is the most consistently efficacious modality of
exercise to improve bone health (e.g., slow loss or slightly improve bone mineral density at
the lumbar spine and hip). In contrast, aerobic training, particularly walking, does not appear
to provide a sufficient stimulus to improve bone outcomes, results that are consistent with
RCTs in persons without cancer. There is insufficient evidence to determine if resistance
training alone improves bone outcomes.
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In non-cancer populations, whether or not resistance plus impact training programs are
safe for individuals with osteoporosis remains controversial(48), thus at this time this
exercise prescription may not be safe for cancer survivors with bone fragility associated
with osteoporosis or bony metastases in the hip or spine (see section 5). Furthermore, it may
not be appropriate for individuals with joint/orthopedic issues and/or stability problems who
may be better served by an exercise program aimed at reducing fall risk. Further research is
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needed to confirm that this recommendation is effective and safe for cancer survivors.
2.4.2 Sleep—Two recent systematic reviews in cancer survivors(49, 50) provided mixed
evidence for overall sleep quality, indicating either a positive effect of walking(49), or no
effect of exercise(50). Four recent RCTs not included in either systematic review have
shown consistent evidence of small to moderate effect sizes on overall sleep quality for
aerobic training(51), in addition to walking specifically(52, 53) and one study reported
evidence of benefit for resistance training(31). In non-cancer populations, there is strong
evidence that moderate to vigorous intensity aerobic training is associated with better overall
sleep quality in the general population(54) and there was some evidence showing benefit
for specific characteristics of sleep, such as total sleep time, sleep onset latency, and sleep
efficiency. Overall, moderate intensity aerobic training, particularly walking, 3–4 times per
week, for 30–40 minutes per session over 12 weeks is recommended.
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2.5 Insufficient Evidence

Insufficient evidence for a specific outcome does not mean that cancer survivors facing these
cancer-related health outcomes will not benefit in other ways from engaging in physical
activity or should remain sedentary. Rather there is insufficient evidence showing that
exercise is beneficial for these specific outcomes based on current evidence and this creates
an obvious gap in knowledge the research community must fill.
2.5.1 Cardiotoxicity—The effect of exercise to prevent or ameliorate cardiotoxicity is an

emerging field of research and promising results for a protective effect of exercise in animal
models and some novel evidence in humans for cardiac function(55), including measures of
left ventricular function(55), and vascular endothelial function, measured as flow-mediated
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dilation(56). More research is needed to understand the impact of various types of cancer,
cancer treatments and exercise prescriptions on both cardiac and vascular function.
2.5.2 Chemotherapy induced peripheral neuropathy—To date, there are too few
high quality trials to interpret the potential of the benefits of exercise for preventing and/or
managing chemotherapy-induced peripheral neuropathy and related side effects, such as
balance impairment and falls(57). In general, exercise appeared safe in the few published
studies, however, the degree of improvement varied for this outcome, and other related
outcomes, such as mobility and balance. Future research should include well controlled
exercise interventions with chemotherapy-induced peripheral neuropathy as a primary
outcome, using both patient-reported outcomes and objective assessment of neuropathy,
balance and mobility, and also rigorously evaluate the safety of training in this group due to
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the known risk of falls.
2.5.3 Cognitive function—While promising results from animal studies are emerging
for a protective effect of aerobic training on cancer treatment related changes in cognitive
function, to date, the evidence in humans is limited(58). The majority of human studies,
so far, have been conducted in breast cancer survivors, using self-reported measures of
cognitive function, and report inconsistent results. While there is compelling evidence
of a positive effect of exercise on cognitive function in older adults and other clinical
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populations(59), specific to cancer, more research is needed in cancer survivors where

cognitive function is the primary outcome, and this outcome is assessed by both self
reported and standardized objective measures of cognitive function.
2.5.4 Falls—There are no randomized controlled trials to date in cancer survivors with
falls as a primary endpoint. There are several challenges to this type of research, including
the relatively rare occurrence of falls and the large sample and time needed to observe a
change in falls from an intervention. Similarly, the causes of falls associated with cancer
treatment have not been fully characterized and may be due to more than an acceleration
of the risks associated with age-related falls (i.e., muscle weakness and poor balance),
but may also be due to treatment-related toxicities such as hearing loss, ataxia, peripheral
neuropathies and fatigue, creating a challenge to develop new exercise-based approaches
to fall prevention. In the absence of any evidence-based fall prevention studies in cancer
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survivors, it seems reasonable to consider standard fall prevention exercise approaches that
reduce the risk of age-related falls for cancer survivors with a fall history to at least reduce
the risk of falls that may be associated with advanced age(60, 61).
2.5.5 Nausea—While a commonly reported benefit of exercise during chemotherapy,

there is limited data from high quality trials with nausea as a primary endpoint to support
this finding outside of an early study demonstrating a reduction by Winningham et al.(62).
Future research could examine the effect of well controlled exercise interventions on nausea
in highly emetogenic regimens to determine if there is an effect. These studies should
account for antiemetic use, duration and intensity of nausea, and function.
2.5.6 Pain—To date most published controlled trials in cancer survivors have examined
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non-specific pain, and included pain as a secondary outcome, which limits the interpretation
of the research. There is early evidence from two high-quality controlled trials where pain
was the primary outcome that a combined home-based aerobic plus supervised resistance
training intervention in women with breast cancer significantly reduced arthralgia associated
with aromatase inhibiter therapy(63) and a supervised resistance training intervention
focused on the upper extremity significantly reduced in shoulder pain in individuals with
head and neck cancer(64). However, more research is needed specifically focused on cancer
related pain. Survivors may be able to exercise with pain that is tolerable and not worsened
by exercise; however, modification or omission of individual exercises that exacerbate pain
may be necessary.
2.5.7 Sexual Function—The majority of research to date has been in men with prostate
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cancer(65, 66) and there is insufficient evidence from controlled trials investigating the
effect of exercise on sexual function during or after cancer therapy. Early promising
results for a positive effect of exercise on sexual function among prostate cancer patients
treated with androgen deprivation therapy has been reported in some trials(67, 68) but not
others(69). While there is compelling evidence of a positive effect of exercise on sexual
function in the general population, for both women(70) and men(71), the significant effects
of cancer therapies on hormonal and anatomical/functional changes (i.e., nerve sparing
versus non-nerve sparing surgeries in prostate cancer) preclude the ability to extrapolate
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those findings to the cancer population.
2.5.8 Treatment Tolerance—Treatment tolerance (i.e., completion of or adherence to

planned therapy) is a complex outcome that likely varies by cancer type, treatment modality
(i.e., radiation therapy, chemotherapy, hormone therapy, immunotherapy), and even specific
drug(s) and protocols. Consequently, determining the effects of exercise on “treatment
tolerance” is a challenging goal and may make it difficult to achieve a high degree of
generalizability. A recent systematic review of exercise and chemotherapy completion rate
concluded that, while promising, the evidence for an exercise benefit to chemotherapy
tolerance is insufficient(72). The effects of exercise on treatment tolerance for radiation
therapy, hormonal therapy (i.e., aromatase inhibitors or androgen deprivation therapy),
targeted therapies or immunotherapy is currently unknown. To understand the effect of
exercise on treatment tolerance, studies would need to be conducted for each combination of
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cancer type and treatment regimen.
2.6 Limitations
The FITT prescriptions provided for several outcomes aim to serve as guidelines for fitness
and healthcare professionals working with cancer survivors. However, the development
of these guidelines had some key limitations that should be kept in mind when working
with individual clients. The majority of available literature is still in the most common
cancers, namely early stage breast cancer and prostate cancers, which limits the ability
to extrapolate to other cancer types or advanced cancers. Though, it could be reasonably
assumed that in the absence of any unique safety concerns for survivors of other types of
cancer that the efficacy of exercise on various outcomes would be similar for survivors
with early stage cancers other than breast and prostate cancer. However, differences among
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cancer survivors by cancer type are known to exist (i.e., demographics, prognosis, treatments
received and associated side effects) and further, there is very little information regarding
the feasibility, safety or benefits of exercise in individuals living with advanced cancer. More
research is needed to advance the level of specificity available in the exercise oncology
literature to serve a broader range of cancer types and stages(73). In addition, there has
historically been incomplete reporting of compliance to a prescribed FITT program in
published studies, likely because tracking and quantifying compliance can be burdensome
(74–76). Thus, it remains possible that some proportion of cancer survivors may not be
able to tolerate the evidence-based FITT, as explicit reporting of adjustments to the exercise
prescription (i.e., dose modification) based on tolerance of individuals has been limited.
Thus, the fitness or healthcare professional should monitor for early signs of poor tolerance
to training and adjust the dose of exercise accordingly even if this means dropping below
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recommended training volumes. Furthermore, understanding the specific efficacy of exercise

for a particular outcome is hampered by the fact that the majority of research to date does
not consider the training principle of initial values by limiting enrollment to individuals
experiencing the specific outcome of interest (i.e., those with sleep issues or high level
of fatigue), rarely examines potential moderators of the exercise response (i.e., baseline
functional capacity), and often draws conclusions about outcomes that are secondary to the
intended design of the study. Finally, a further understanding of dose response is limited
by a paucity of trials that directly compare two or more levels of exercise training (e.g.,
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high versus low intensity exercise) on cancer-related outcomes(77) or compare settings (e.g.,
supervised versus home-based)75. Clearly, more research to address these knowledge gaps is
warranted so that recommendations can continue to improve in scope and specificity.
2.7 Other exercise modes

There is also increasing interest in the safety and efficacy of types of exercise that fall
outside of traditional modes of aerobic and resistance training. In a recent systematic
review of the role of yoga in symptoms management for cancer survivors, yoga both
during and after cancer treatment was reported to improve quality of life and fatigue, while
further research is needed to confirm the observed potential to improve sleep, depressive
symptoms, anxiety/distress, and cancer-related cognitive change(78). However, the literature
is reflective of practices for many different types of yoga, including those that incorporate
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non-exercise features such as breathing or meditation and which use a wide variety of
prescriptions (e.g., frequency, duration, with/without home practice), making it difficult to
generate a definitive prescription. While there is also insufficient evidence at this time for
a definitive prescription around safety and efficacy for other types of exercise for cancer
survivors, such as dragon boating(79, 80), recreational sports(81), wall/rock climbing(82),
triathalon(83), or high intensity interval training(84), research is on-going.
3 EFFECTS OF CANCER TREATMENT AND ADVERSE EFFECTS

RELEVANT TO EXERCISE
To best evaluate a cancer survivor’s exercise tolerance and prescribe a safe and effective
exercise program, it is necessary for fitness professionals to know about the type and extent
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(i.e. stage) of cancer a person has. Fitness professionals must also be familiar with the
common treatment approaches to cancer, the side effects and symptoms these treatments can
cause, and the subsequent impact on exercise tolerance (Table 3). The treatment approach
used will differ by type of cancer, stage of disease, cancer subtype, patient health and
many other considerations. Treatment modalities may include a combination of surgery,
radiation, and systemic therapies, including cytotoxic chemotherapy, newer targeted agents
including immune checkpoint inhibitors, and hormonal therapy. When individuals are on
active cancer treatment, working closely with the oncology treatment team is recommended,
as treatment approaches change frequently and understanding the side effects of newer
treatments continues to evolve.
The impact of cancer treatment on exercise tolerance may further depend upon the pre
diagnosis health and functional capacity of the individual. Furthermore, fitness professionals
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should be aware of and respectful of the fact that individuals diagnosed with cancer
commonly have many concerns, such as life expectancy, employment issues, and family
matters, that may limit prioritization of exercise in their lives.
4 MEDICAL CLEARANCE & EXERCISE TESTING

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Both the diagnosis of cancer and curative cancer treatments may affect the underlying
safety of exercise training. Guidance for the indications of medical clearance prior to
exercise testing and/or training, as well as how exercise testing should be adapted for cancer
survivors, can be useful for creating a safe and effective exercise prescription. Where this
information is available elsewhere and to avoid redundancy, the reader will be referred to
specific publications.
4.1 Medical Clearance Prior to Exercise

Given the diversity of tumor types and side effect of different cancer treatments, including
the potential acceleration of cardiovascular disease (CVD), the question of whether or not
cancer survivors require medical clearance (i.e., approval from a medical professional to
engage in exercise) prior to starting an exercise program is always relevant. Recently, the
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ACSM updated its pre-participation exercise guidelines for all persons in an attempt to
reduce barriers to exercise by removing a requirement for medical clearance for individuals
whose risk of an adverse cardiac event during exercise are low, including exercise naïve
persons(85). Pre-participation guidelines for evaluating the need for medical clearance for
non-cancer comorbidities should be applied in cancer survivors to minimize risks of adverse
exercise-related events. The ACSM pre-participation guidelines do not explicitly address
risks for adverse events and/or injury during exercise that are specific to the adverse effects
of cancer treatment. Therefore, we have referred to the National Comprehensive Cancer
Network (NCCN) Survivorship Guidelines(8) to frame recommendations for when medical
clearance and/or further medical evaluation by a medical professional is indicated, as well as
the level of supervision during exercise training for cancer survivors to ensure safety based
on the disease and treatment related side effects (Table 4).
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4.2 Exercise testing

Ideally, cancer survivors should receive a comprehensive assessment of all components of
health-related physical fitness (i.e., cardiorespiratory fitness, muscle strength and endurance,
body composition and flexibility), with some specific cancer-specific considerations (BOX
2), in order to individualize an exercise prescription. However, requiring a comprehensive
physical fitness assessment prior to starting exercise may create an unnecessary barrier
to starting activity. For this reason, no assessments are required to start low intensity
aerobic training (i.e., walking or cycling), resistance training with gradual progression, or a
flexibility program in most survivors. Medical clearance may still be indicated as previously
described depending on exercise and health history and presence of cardiovascular, renal or
metabolic symptoms(85).
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5 EXERCISE SAFETY & TRAINING TOLERANCE

5.1 Safety of exercise training
The overall conclusion from the 2010 Roundtable was that exercise is generally safe for
cancer survivors(6) and this has not changed based on the majority of studies conducted
since that time. It should be recognized that the majority of available evidence on the safety
and efficacy of exercise during and following cancer treatment is derived from RCTs of
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supervised and/or home-based prescribed exercise, and trials in breast cancer survivors(17,
31, 32). Hence the individuals enrolled in studies commonly meet pre-specified eligibility
criteria for age, comorbidities, physical ability, largely based out of academic and/or medical
centers, and were willing to participate in research. This often results in a sample that
is healthier or with higher physical function and exercise motivation that may not fully
generalize to the broader population of cancer survivors. Depending on the nature and
extent of a survivor’s presenting problems they may not be able to adequately and/or safely
engage in the levels of exercise outlined in this recommendation. In these cases, we again
refer to the NCCN guidelines (Table 4). Physical therapy or medical evaluation might be
a bridge to inform appropriate modifications to an individual’s exercise program and/or
correct toxicities, impairments and limitations that prevent a survivor from working toward
recommended levels of exercise.
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5.2 Exercise Tolerance

Exercise has well established health benefits in persons without cancer, thus a key
consideration in exercise trials has been whether or not cancer survivors can tolerate the
doses of exercise known or hypothesized to effectively improve physical fitness and in
turn, associated cancer-related outcomes. Research to date supports the potential of cancer
survivors to respond positively to an exercise training stimulus by improving individual
components of physical fitness, including cardiorespiratory fitness (i.e., VO2peak)(86),
muscular strength and endurance(87, 88), body composition(89). However, an individual’s
response to a given exercise stimulus may vary due to the direct effects of cancer treatments
on physiological systems (i.e., anemia), side effects of cancer treatment (i.e., cancer-related
fatigue may lower exercise tolerance), or demographics factors (i.e., age)(90). Furthermore,
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during active treatment an individual’s ability to tolerate exercise may fluctuate from day
to day or week to week. Understanding of these interactions is a topic of ongoing research,
especially with the emergence of novel therapies.
Specific to cardiorespiratory fitness, during chemotherapy treatment there is a well

documented decline in cardiorespiratory fitness, as measured by VO2peak or 6-minute walk
test(4). Randomized trials of aerobic exercise during adjuvant chemotherapy demonstrate
a preservation of, or an improvement in, cardiorespiratory fitness, especially in those with
low initial values(86), while others report better improvement in those with higher initial
values(91). Aerobic exercise during adjuvant chemotherapy does not appear to stimulate
greater production of red blood cells(92), so improvements in cardiorespiratory fitness
are contingent on other central (i.e., cardiac function, plasma volume) and peripheral
adaptations (i.e., improved vascularization and mitochondrial enzyme function)(93).
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Specific to muscular strength, loss of muscle strength and endurance is common due to
deconditioning or as a side effect of cancer treatment. For example, androgen deprivation
therapy (ADT), which is commonly used as treatment for prostate cancer, results in
an abrupt loss of lean body mass accompanied by a reduction in muscle strength and
endurance(94, 95). In the absence of the anabolic drive from testosterone, men on ADT
may not be able to build lean mass in response to resistance training; however, several
trials that have employed resistance training, or combined with aerobic training, have
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reported small, but statistically significant improvements in lean body mass after 12–36
weeks of training(96) While sarcopenia is related to muscle weakness and contributes
to poor functioning in older adults, neuromuscular contributions explain up to 50% of
variation in muscle strength in older adults, thus resistance training in the setting of ADT
or deconditioning may still effectively improve muscle strength in the absence of gains in
muscle mass(97).
Specific to body composition, maintenance of body weight can be difficult during treatment
for some cancers, where loss of weight and lean body mass is a common concern,
such as advanced colon, lung cancer and pancreatic cancer(98); whereas weight gain can
be a common side effect of chemotherapy and anti-estrogen therapy for breast cancer
or anti-androgen therapy for prostate cancer(99). Moreover, obesity is a risk factor for
multiple cancers, including postmenopausal breast, renal cell and endometrial cancer, thus
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these survivors are more likely to be overweight or obese at the time of diagnosis(100).
In cases where weight and lean body mass loss may be a side effect of treatment, the
fitness professional needs to ensure that exercise training is not creating an excess energy
deficit (i.e., energy expenditure exceeds adequate dietary energy and nutrient intake) that
contributes to weight loss and can aggravate fatigue(101, 102). Working with a trained
oncology dietician who can advise on dietary modifications that would support adequate
fuel availability and replacement during and post exercise, respectively, may be prudent. For
cases where survivors may be prone to weight gain and/or obesity, the exercise professional
should be aware of the safety considerations related to exercise, including orthopedic
limitations and cardiovascular disease risk(85, 103). If weight loss is implicated in the health
goals for these individuals, it may be prudent for the exercise professional and/or survivor to
partner with a registered dietician to provide dietary recommendations that can complement
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an exercise program.
Specific to musculoskeletal flexibility, surgery can result in temporary or more permanent

reductions in joint range of motion, and extensibility of muscle, tendon, fascia and skin.
Exercise professionals should be aware of surgical sites and if abnormal movement patterns
are observed, adapt the proposed movements to avoid placing abnormal strain on other body
structures and consider referral to physical therapy in efforts to address restrictions.
6 IMPLEMENTING FITT PRESCRIPTIONS IN PRACTICE

Based on the current literature, an effective exercise prescription that most consistently
addresses health-related outcomes experienced due to a cancer diagnosis and cancer
treatment includes moderate intensity aerobic training at least 3 times per week, for at least
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30 minutes, for at least 8–12 weeks. The addition of resistance training to aerobic training, at
least 2 times per week, using at least 2 sets of 8–15 repetitions at least 60% of one repetition
maximum, appears to results in similar benefits (BOX 3). Exercise programs that only
prescribe resistance training are also efficacious at improving most health-related outcomes,
though for some specific outcomes the evidence is either insufficient or suggestive that
resistance training alone may not be enough (e.g., depressive symptoms). Exercise programs
that were supervised appear to be more effective than strictly unsupervised or home
based programs, though it is unclear whether or not this is because a higher dose of
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exercise may be better achieved with supervised training or from other attributes of this
setting (i.e., more attention, motivation, reinforcement, selection bias). While a variety of
professionals delivered supervised interventions in the research literature (e.g., exercise
physiologists, certified exercise instructors, nurses, physical therapists) determining the type
of professional that could maximize outcomes was beyond the scope of this paper and the
available evidence.
However, the fitness professional should be prepared to an create exercise program

that meet their clients’ needs. A customized program may not yet resemble or reach
the exercise programs recommended in these guidelines, such that a goal may be
to strive toward preparing the client to engage in recommended types and levels of
exercise over their lifetime as outlined in the 2018 Physical Activity Guidelines for
Americans(54). There is consistent observational evidence that engaging in physical activity
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following a cancer diagnosis reduces the risk of cancer-specific and all-cause mortality for
individuals diagnosed with early stage breast, colorectal and prostate cancer(104). Special
considerations and modifications to exercise programs have been adapted from the NCCN
guidelines (Table 5). Finally, as part of the ACSM Roundtable efforts, oncologists are
being asked to “Assess, Advise, and Refer”, in order to connect cancer survivors to the
most appropriate available exercise programming. A registry of programming is available at
www.exerciseismedicine.org/movethruca (105).
7 SUMMARY AND FUTURE DIRECTIONS

The 2018 ACSM Roundtable recommendations were made possible due to the increase in
the availability of high quality randomized controlled trials of exercise in cancer survivors
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published after the 2010 recommendations were issued. This allowed for the development
of more specific evidence-based exercise prescription to improve common side effects
of a cancer diagnosis and treatment, namely anxiety, depressive symptoms, fatigue, health
related quality of life, and physical function, along with safety of exercise training in
persons with or at risk of breast-cancer related lymphedema. Future research is needed to
determine the efficacy of exercise to improve other outcomes, including those identified here
under the emerging or insufficient evidence categories. In addition, the literature remains
insufficient for further detailing prescriptions according to cancer type, timing of treatment,
and/or types of treatment, while exercise prescriptions were rarely based on studies that
directly compared varying FITT components, such as a head-to-head trial of low versus
high intensity training. Thus, as the evidence base continues to grow in other cancer sites
and keeps pace with the evolution of cancer treatment, as well as trial designs broaden to
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include multiple treatment arms, the next generation of exercise prescriptions could have the
specificity to move exercise oncology toward the same goal as precision oncology where
treatment is matched to the specific characteristics of a person’s cancer.
Supplementary Material
Refer to Web version on PubMed Central for supplementary material.
Acknowledgements:
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Funding for the Roundtable was provided by: American College of Sports Medicine,, American Cancer Society,
American Academy of Physical Medicine and Rehabilitation, American Physical Therapy Association, Canadian
Society for Exercise Physiology, Exercise and Sports Science Australia, German Union for Health Exercise and
Exercise Therapy (DVGS), McMillan, Royal Dutch Society for Physical Therapy (KVDP), Sunflower Wellness.
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Box 1.
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List of common acute, long term and late effects of cancer for review
of evidence for therapeutic efficacy of exercise and subsequent exercise
prescriptions
• Anxiety
• Bone health
• Cardiotoxicity
• Chemotherapy-induced peripheral neuropathy
• Cognitive function
• Depressive symptoms
• Falls
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• Fatigue
• Health-related quality of life
• Lymphedema
• Nausea
• Pain
• Physical function
• Sexual function
• Sleep
• Treatment tolerance
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BOX 2.
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Exercise testing recommendations:
• Standard exercise testing methods are generally appropriate for patients with cancer who do not require
medical clearance or who have been medically cleared for exercise with the following considerations:
• Be aware of a survivor’s health history, comorbid chronic diseases and health conditions, and any general
exercise contraindications before commencing health-related fitness assessments or designing the exercise
prescription(85).
• Be familiar with the most common toxicities associated with cancer treatments including increased risk for
fractures and cardiovascular events, along with neuropathies or musculoskeletal morbidities related to specific
types of treatment
• Health-related fitness assessments may be valuable for evaluating the degree to which components of
fitness have been affected by cancer-related fatigue or other commonly experienced symptoms that impact
function(106)
• In principle, there is no evidence that the level of medical supervision required for symptom-limited
or maximal cardiopulmonary exercise testing need to be different for patients with cancer than for other
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populations(85).
• The evidence-based literature indicates 1-RM testing is safe among survivors of breast and prostate cancer
without bony metastases(6)
• Among patients with bony metastases or known or suspected osteoporosis routine assessments of muscle
strength and/or endurance involving musculature that attaches to and/or acts on a skeletal site that contains
bone lesions should be avoided(107). For example, 1-RM testing for leg strength (e.g, leg press) should be
avoided in patients who have bony metastases in the proximal femur (i.e., hip) or vertebrae. Other sites where
lesions are absent could be tested. In this example, if the patient had no lesions in the upper body, 1-RM for
a chest press or 1-RM for a seated row might be feasible, given no other contraindications. Medical clearance
from a physician (i.e., orthopedic or radio-oncology) may be mandatory depending on scope of practice or
protocols at a specific site/facility.
• Older survivors and/or survivors treated with neurotoxic chemotherapy (typical for breast, colon, lung, ovarian
cancers) may especially benefit from a standard assessment of balance and mobility to assess fall risk(108)
• CVD has become a competing cause of morbidity and mortality for survivors of cancer with a favorable
prognosis(109). Given the potential for underlying CVD, cancer survivors should be screened for evident
or underlying CVD using the ACSM pre-participation guidelines (see below) and if implicated have a
cardiopulmonary exercise test prior to beginning an exercise program(110).
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Box 3:
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Expected patient benefits from exercise training by mode
Aerobic Resistance Aerobic plus Resistance

Reduced anxiety Less fatigue Reduced anxiety
Fewer depressive symptoms Better QoL Fewer depressive symptoms
Less fatigue No risk of exacerbating Less fatigue
Better QoL lymphedema Better QoL
Improved perceived physical Improved perceived physical Improved perceived physical
function function function
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FIGURE 1:
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Decision tree on the level of evidence for effects (RCT) sufficient to merit an exercise
prescription (FITT Rx). aAdapted with permission from Weggemans RM, Backx FJG,
Borghouts L, et al. The 2017 Dutch Physical Activity Guidelines. Int J Behav Nutr Phys Act.
2018;15(1):58.
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Table 1.
Participating organizations
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American College of Sports Medicine (ACSM) *, † Exercise and Sports Science Australia *, †
American Cancer Society (ACS) *, † German Union for Health Exercise and Exercise Therapy
(DVGS) *, †
American Academy of Physical Medicine and Rehabilitation (AAPMR)*, MacMillan *, †

†
American Physical Therapy Association (APTA)* National Cancer Institute (U.S.)
American Congress of Rehabilitation Medicine National Comprehensive Cancer Network †
American College of Lifestyle Medicine † Royal Dutch Society for Physical Therapy (KVDP) *, †
Canadian Society for Exercise Physiology *, † Society for Behavioral Medicine †
Centers for Disease Control † Sunflower Wellness *, †

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Commission on Accreditation of Rehabilitation Facilities †
Legend
*
Roundtable Partner Organizations
†
Organizations that provided official endorsement
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Table 2.
Cancer-related health outcome with sufficient evidence for development of FITT prescription
Outcome Type† Intensity Duration Frequency Length Setting Dose response Special Evidence primarily
(min) or (sessions (weeks) (supervised, home considerations from these cancer types.
Sets (reps) per week) based or
Campbell et al.
combination)
Anxiety Aerobic 60–80% HRmax 30–60 3 12 Supervised more Moderate to Not known Breast (majority),
60–80% VO2max effective vigorous may be prostate, colorectal,
RPE 13–15 more effective gynecological (ovarian,
than light to endometrial, cervical),
moderate head and neck, lung,
hematological cancer
Resistance Efficacy not NA NA NA NA NA NA
demonstrated
Aerobic + 60–80% HRmax 20–40 2–3 6–12 Supervised or None observed Not known
Resistance 60–80% VO2max combination of
RPE 13–15 supervised &
home-based
65–85% 1RM 2 sets 2–3 6–12
8–12 reps
Depressive Aerobic 60–80% HRmax 30–60 3 12 Supervised more Benefit up to Not known Breast (majority),
Symptoms 60–80% VO2max effective 180 min/wk prostate, colorectal,
RPE 13–15 hematological
Resistance Efficacy not NA NA NA NA NA NA

demonstrated
Aerobic + 60–80% HRmax 20–40 3 12 Supervised or None observed Not known

Resistance 60–80% VO2max combination of
RPE 13–15 supervised &
home-based
65–85% 1RM 2 sets 2–3 6–12
8–12 reps
Fatigue Aerobic 65% HRmax 30 3 12 No dose No evidence of Breast (majority),

45% VO2max response by benefits from light prostate, mixed
RPE 12 Supervised and intensity; intensity
unsupervised possible >
appear similarly benefits with ↑
effective duration &
length of
program
Resistance 60% 1RM 2 sets 2 12 Supervised and None observed Not known
RPE 12 12–15 reps unsupervised
appear similarly
effective
Aerobic + 65% HRmax 30 3 12 Supervised and None observed Not known

Resistance 45% VO2max unsupervised
RPE 12 appear similarly
effective
Page 28
combination)
60% 1RM 2 sets 2 12
RPE 12 12–15 reps
Campbell et al.
Health-related Aerobic 60–80% HRmax 30 2–3 12 Supervised more None observed NA Breast (majority),
Quality of Life RPE 11–13 effective prostate, colorectal, lung,
head and neck, bladder,
Resistance 60–75% 1 RM 2–3 sets 2–3 12 Supervised or None observed NA gynecological, mixed,
RPE 13–15 8–15 reps combination of hematological cancer,
supervised & hematopoietic stem cell
home-based transplant
Aerobic + 60–80% HRmax 20–30 2–3 12 Supervised more None observed AT & RT combined
Resistance RPE 11–13 effective most effective
60–80% 1RM 2 sets 2–3 12

RPE 12–14 8–15 reps
Lymphedema* Aerobic NA NA NA NA NA NA Generally safe, Breast cancer-related

as no significant lymphedema only
increase in number
of lymphedema
related adverse
events reported in
RCT of aerobic
exercise
Resistance 60–70% 1RM 1–3 sets 2–3 52 All of NA Start resistance a

RPE 15 8–15 reps the interventions low weight and
reviewed started progress slowly
with supervision to
teach the exercises.
Aerobic + NA NA NA NA NA NA NA
Resistance
Physical Aerobic 60–85% HRmax 30–60 3 8–12 Supervised more If unsupervised, NA Breast (majority),
Function 60–85% VO2max effective requires higher prostate, colorectal, lung,
RPE 12–13 weekly exercise bladder, head and neck,
expenditure hematological cancer,
(unclear what the hematopoietic stem cell
threshold is) transplant
Resistance 60–75% 1RM 2 sets 2–3 8–12 Limited evidence to NA NA

RPE 13–15 8–12 reps determine benefit
of unsupervised
Aerobic + 60–85% HRmax 20–40 3 8–12 Both supervised & NA Community-based

Resistance 60–85% VO2max home-base suitable interventions that
RPE 12–13 in older adults met in groups
& used behaviour
60–75% 1RM 2 sets 2–3 8–12 change strategies
RPE 13–15 8–12 reps may produce larger
Page 29
combination)
effects in older
adults
Campbell et al.
†
Mode: For aerobic activity, this includes walking, cycling ergometer and other forms of traditional aerobic exercise; for resistance, this includes machine-based and free weights.
Legend
*
recommendation for breast cancer-related lymphedema only.
Abbreviations: NA, not applicable.
Page 30
Table 3.
Potential impact of cancer treatments on exercise tolerance and safety
Surgery Chemotherapy Radiation Anti-hormonal therapy Targeted Therapy or

(surgical or a
pharmaceutical) Immunotherapy
Campbell et al.
Cardiovascular changes Cardiac damage or increased CVD risk √ √ √ √
Endocrine changes
Worsening bone health √ √ √
Changes in body composition (weight gain) √ √
Changes in body composition (weight loss/muscle √ √ √ √ √

mass loss)
Gastrointestinal changes
Nausea √ √
Diarrhea √ √ √
Altered GI function √ √ √ √
Immune changes Impaired immune function and/or anemia √ √ √ √
Metabolic changes
Development/worsening of metabolic syndrome √ √ b

√
Neurological changes Peripheral Neuropathy √
Cognitive changes √ (brain surgery) √ √ √
Pulmonary changes Altered lung function or pneumonitis √ (lung surgery) √ √
Skin changes
Redness, irritation √
Rashes √ √
Reduced ROM √ (by healing at √
surgical site)
Fatigue √ √ √ √ √
c √ √
Lymphedema
Pain General √ √ √ √ √
Myalgia/Arthralgia √ √ √
Adapted from Schmitz et al. ACSM 2010 Roundtable

Page 31
Legend
a
Depends on type or target of agent
b
Especially common with PI3kinase inhibitors
c
Can occur in any type of cancer when and where lymph nodes are surgically resected and/or radiation over lymph nodes.
Abbreviations: CVD, cardiovascular disease; GI, Gastrointestinal.

Campbell et al.
Page 32
Table 4.
Adapted National Comprehensive Cancer Network Triage Approach Based on Risk of Exercise-Induced
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Adverse Events
Description of Patients Evaluation, Prescription and Programming Recommendations

No comorbidities No further pre-exercise medical evaluation*
Follow general exercise recommendations
Peripheral neuropathy, arthritis/musculoskeletal issues, poor Recommend pre-exercise medical evaluation*

bone health (e.g., osteopenia or osteoporosis), lymphedema Modify general exercise recommendations based on assessments
Consider referral to trained personnel†
Lung or abdominal surgery, ostomy, cardiopulmonary disease, Pre-exercise medical evaluation* and clearance by physician prior to
ataxia, extreme fatigue, severe nutritional deficiencies, exercise
worsening/changing physical condition (i.e., lymphedema
exacerbation), bone metastases Referral to trained personnel†
Legend
†
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Rehabiliation specialists (i.e., physical therapists, occupational therapists, physiatrists) and certified exercise physiologists (i.e., American
College of Sports Medicine Certified Clinical Exercise Physiologist (ACSM-CEP), Canadian Society for Exercise Physiology Certified Exercise
Physiologist (CSEP-CEP), Exercise & Sport Science Australia Accredited Exercise Physiologist (ESSA-AEP)).
*
Medical evaluation – per NCCN guidelines for specific symptoms and side effects
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Table 5.
Exercise programming considerations for specific cancer survivors

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Consideration Recommendations.
Bone loss / bone • Avoid contraindicated movements that place an excessively high load on fragile skeletal sites. These include the
metastases: following: high-impact loads, hyperflexion or hyperextension of the trunk, flexion or extension of the trunk with added
resistance, and dynamic twisting motion
• Specific guidance on how to modify exercise programs based on the site of bony lesions is provided elsewhere(107, 111)
• Preventing falls must also be a goal of therapy, since falls play an important role in fracture etiology (112).
• Be aware of signs and symptoms of bone metastases in survivors, as well as common locations where these occur
(i.e., spinal vertebrae, ribs, humerus, femur, pelvis). Bone pain can be an initial sign of skeletal metastases thus, exercise
trainers should refer survivors who report pain back to the medical team for clinical evaluation prior to continuing exercise
Lymphedema • To date, there is insufficient evidence to support or refute this clinical advice to wear a compression garment during
exercise to prevent or reduce symptoms of breast cancer-related upper body lymphedema. Therefore, it is recommended
that exercise professionals provide this information as part of client education and defer to an individual client’s
preference regarding use of a compression sleeve.
• Being overweight or deconditioned have been associated with a higher risk of developing cancer-related lymphedema in
observational studies, at this time there is insufficient evidence that weight loss or improving aerobic fitness can lower the
risk of developing cancer-related lymphedema(113).
•
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Older adults • Physical problems reported by cancer survivors, such as cognitive difficulty, neuropathy, sarcopenia, muscle
weakness, slowing, and fatigue, may be similar to those of older people without cancer, but cancer treatment can
accelerate these declines(114–116)
• Exercise professionals will need to combine ACSM guidelines on exercise programming for older adults(117) with the
recommendations in this publication.
• Integrate fitness and functional assessments prior to beginning an exercise program to more accurately determine
baseline functional abilities.
Ostomy • Empty ostomy bag before starting exercise

• Weight lifting/resistance exercises should start with low resistance and progress slowly under the guidance of trained
exercise professionals. People with an ostomy may be at an increased risk of parastomal hernia. To regulate intra
abdominal pressure, correct lifting technique and good form is required. Avoid use of a Valsalva maneuver(118, 119).
• Modify any core exercises which cause excessive intra-abdominal pressure, namely a feeling of pressure or observed
bulging of the abdomen.
• Those with an ileostomy are at increased risk of dehydration. Get medical advice on ways to maintain optimum
hydration prior, during and after exercise.
• Those doing contact sports or where there is a risk of a blow to the ostomy may wish to wear an ostomy protector/shield.
Peripheral • Stability, balance, and gait should be assessed before engaging in exercise; consider balance training as indicated
Neuropathy • Consider alternative aerobic exercise (stationary biking, water exercise) rather than walking if neuropathy affects
stability or use treadmill with safety handrails
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• Resistance training recommendations:

○ Monitor discomfort in hands when using hand-held weights
○ Consider using dumbbells with soft/rubber coating, and/or wear padded gloves
○ Consider resistance machines over free weights(120)
Stem cell • Home-based exercise encouraged

transplantation • A full recovery of the immune system recommended before return to gym facilities with the general public
• Start with light intensity, short durations but high frequency and progress slowly
• Exercise volume (intensity and duration) should be adapted on a daily basis based on the individual’s presentation
Symptom • Symptoms and side effects of cancer treatment rarely appear in isolation; rather, symptom clusters are the norm (i.e.,
Clusters fatigue, pain, sleep disturbance), especially during cancer treatment and in those with advanced disease(121).
• Exercise professionals must be aware of this complexity and be prepared to refer clients/patients back to the medical
team (i.e., rehabilitation or oncology physician, general practitioner, or nurse) for review and management of symptoms
when safety concerns develop or when target symptom (e.g., fatigue) is not responding as expected.
Sun Safety • In addition to melanoma survivors(122), survivors of cancer at other primary sites may be at increased risk for
secondary skin cancers(123)
• Exercise professionals should recommend that cancer survivors engage in sun protective practices when exercising
outdoors(124).
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Exercise Guidelines for Cancer Survivors: Consensus statement

1Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver,

14Department of Epidemiology and Biostatistics, University of California San Francisco, San

Methods: A second Roundtable was convened in 2018 to advance exercise recommendations

treatments and/or outcomes.

the 1990’s and 2000’s challenged this advice.

In 2010 the American College of Sports Medicine convened a Roundtable meeting

outcomes; 2) provide evidence-based FITT (frequency, intensity, time, type) prescriptions

2. UPDATE TO EVIDENCE-INFORMED EXERCISE PRESCRIPTIONS

2.2 Methodology for Evidence Review

were identified, the available RCTs were reviewed.

2.3 Strong Evidence

2.3.2 Depressive Symptoms.—Moderate intensity aerobic training performed three

2.3.4 Health-related Quality of Life (HRQoL)—Combined moderate intensity

2.3.5 Lymphedema—There is a history of clinical recommendations to refrain from

2.3.6 Physical Function—Moderate intensity aerobic training, resistance training or

exercise appears to be more effective than unsupervised or home-based interventions(32),

2.4 Moderate Evidence

2.5 Insufficient Evidence

2.5.1 Cardiotoxicity—The effect of exercise to prevent or ameliorate cardiotoxicity is an

the known risk of falls.

populations(59), specific to cancer, more research is needed in cancer survivors where

2.5.5 Nausea—While a commonly reported benefit of exercise during chemotherapy,

those findings to the cancer population.

2.5.8 Treatment Tolerance—Treatment tolerance (i.e., completion of or adherence to

cancer type and treatment regimen.

recommended training volumes. Furthermore, understanding the specific efficacy of exercise

2.7 Other exercise modes

3 EFFECTS OF CANCER TREATMENT AND ADVERSE EFFECTS

4 MEDICAL CLEARANCE & EXERCISE TESTING

4.1 Medical Clearance Prior to Exercise

4.2 Exercise testing

5 EXERCISE SAFETY & TRAINING TOLERANCE

5.2 Exercise Tolerance

Specific to cardiorespiratory fitness, during chemotherapy treatment there is a well­

Specific to musculoskeletal flexibility, surgery can result in temporary or more permanent

6 IMPLEMENTING FITT PRESCRIPTIONS IN PRACTICE

However, the fitness professional should be prepared to an create exercise program

7 SUMMARY AND FUTURE DIRECTIONS

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• Chemotherapy-induced peripheral neuropathy

• Health-related quality of life

Exercise testing recommendations:

Expected patient benefits from exercise training by mode

Aerobic Resistance Aerobic plus Resistance

American Academy of Physical Medicine and Rehabilitation (AAPMR)*, MacMillan *, †

American Physical Therapy Association (APTA)* National Cancer Institute (U.S.)

American Congress of Rehabilitation Medicine National Comprehensive Cancer Network †

Canadian Society for Exercise Physiology *, † Society for Behavioral Medicine †

Centers for Disease Control † Sunflower Wellness *, †

Commission on Accreditation of Rehabilitation Facilities †

Specific to cardiorespiratory fitness, during chemotherapy treatment there is a well

American Academy of Physical Medicine and Rehabilitation (AAPMR), MacMillan , †